Transcript ENTROPION - zu.edu.eg

Prepared by
Khairul Anwar Limat
Nazri Ahmad
Salaamy Mat Kassim
Ophthalmology Department
4th Year Zagazig University
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Entropion is a medical condition in which the
eyelid (usually the lower lid) folds inward. It is
very uncomfortable, as the eyelashes rub
against the cornea constantly
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Spastic Entropion
Cicatricial Entropion
Senile Entropion
Congenital Entropion
Infantile Entropion
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Redness and pain around the eye
Sensitivity to light and wind
Sagging skin around the eye
Excessive tears
Decreased vision, especially if the cornea is
damaged
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Spastic closure of the eyelids allows the
orbicularis oculi muscle to overwhelm the
oppositional action of the lower eyelid
retractors, resulting in an inturning of the
eyelid margin and further irritation of the
ocular surface from the inturned eyelashes.
Occurs when spasm of Muscle of Riolan (due
to irritation) and lack of support of lid by the
globe.
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Treatment of spastic entropion may be of:
Removal of cause of irritation firstly.
Canthoplasty
Skin and muscle operation by excision of parts of skin and
orbicularis muscle.
Wheeler’s operation.
Ocular lubrication and tear preparations are helpful for protecting
the ocular surface.
Small amounts of botulinum toxin (BOTOX®) (approximately 5 U)
are quite effective for the treatment of spastic entropion by
weakening the pretarsal orbicularis oculi muscle.
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Occurs due to cicatrization of palpebral conjunctiva.
These patients usually will display scar tissue of the
conjunctiva, usually a result of trauma, chemical burns,
Stevens-Johnson syndrome, ocular cicatricial
pemphigoid (OCP), infections, or local response to
topical medication.
Examination of the tarsus and palpebral conjunctiva
usually will point to the diagnosis in these cases.
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Procedures for the repair of cicatricial
entropion
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Depending on the degree of scarring and entropion,
the etiology of the cicatricial changes, and the status
of the tarsal plate.
Mild cases can be treated with a transverse
blepharotomy with marginal rotation (Wies
procedure).
More extensive scarring may require oral mucous
membrane (eg, buccal mucosa) or cadaveric dermis
(eg, Alloderm) grafts.
Snellen’s Operation may be done in upper lid entropion.
 Webster’s operation may be done in lower lid entropion.
 Temporizing Quickert-Rathbun sutures are effective for
many cases of spastic entropion.
 Full-thickness eyelid sutures (usually gut suture) from the
inferior fornix anteriorly toward the lashes are used to
torque the eyelid margin away from the globe. Tissue
reaction to the gut suture helps to create a cicatrix in the
eyelid that maintains the eyelid in the everted position.
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Cicatricial entropion of upper lid.
There is scar tissue involving tarsal conjunctiva.
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Also known as involutional entropion.
The patient may exhibit horizontal laxity of the
medial and/or lateral canthal tendons.
Vertical lid laxity due to weak lower lid retractor.
Patients usually have an involution of the posterior
eyelid retractors, with the eyelid inturning in much
the same manner as with spastic entropion.
Involution of the soft tissues of the orbit,
particularly the orbital fat, may lead to
involutional enophthalmos, which in turn can lead
to unstable eyelid position with entropion.
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Treatment of senile entropion:
It may require repair of the horizontal laxity via
medial and/or lateral canthal tightening.
 Transmarginal rotation(Weis)
 Plication of lower lid retractors(Jones)
 Tucking of palpebral ligaments
 A small amount of the pretarsal orbicularis oculi can
be resected concurrently to prevent further
overriding of the tarsus
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Involutional entropion. Note overriding orbicularis oculi muscle,
eyelid margin entropion, and relative enophthalmos with deep
superior sulcus.
Involutional entropion. Correction of entropion with eyelid
retractor reattachment and lateral canthopexy.
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The congenital form of entropion is very rare. It
may arise due to a number of underlying
developmental abnormalities, usually in the lower
eyelid. Facial nerve paralysis in the pediatric
population has been shown to be associated with
lower lid entropion.
Dysgenesis of the lower eyelid retractors may be
present creating instability in the eyelid with
consequent entropion, or a paucity of tissue may
be present vertically in the posterior lamella of the
eyelid.
Occur with microphthalmos.
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Occurs in plump children due to subcutaneous
fat. It is self limiting.
1-Trichiasis – Presence of more than 4 maldirected lashes rubbing against the conjunctiva.
2-Distichiasis – Congenital Trichiasis
3-Trachoma – Infective Keratoconjunctivitis
caused by Chlamydia Trachomatis.
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Medical therapy may be warranted for patients who
decline surgery and as a temporizing maneuver in
patients who may improve spontaneously.
Ocular lubrication and tear preparations are helpful
for protecting the ocular surface.
Eyelid hygiene, antibiotics, and corticosteroids are
useful.
Small amounts of botulinum toxin (BOTOX®)
(approximately 5 U) are quite effective for the
treatment of spastic entropion by weakening the
pretarsal orbicularis oculi muscle.
Patients with cicatricial entropion secondary to ocular
cicatricial pemphigoid may benefit from systemic
chemotherapy, usually dapsone.
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Complications
Any surgical procedure can have immediate or delayed complications.
Immediate complications include hemorrhage, infection, wound
dehiscence, graft failure (donor and recipient sites), corneal injury, and
recurrence of the entropion, as well as consecutive ectropion.
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Hemorrhage is treated with cauterization of the bleeding points, and infection is
managed with antibiotics directed at culture-specific organisms.
Wound dehiscence may require immediate surgical repair if extensive or
conservative management if mild.
Maintain grafts by stenting the grafted site for the purpose of graft immobilization.
Graft failure may require debridement with delayed re-operation.
Donor site complications, particularly bleeding, are managed with appropriate
packing material.
Consecutive ectropion may occur and may respond to conservative
observation during the healing period with late secondary repair.